I have often seen home blood pressure monitoring machines in high street chemists, but they are pricey. Are they any good?

Some are, but others are not accurate or reliable. Ask your doctor for advice on which one to buy and then get it checked against the doctor’s machine. Ask the nurse if you are not sure how to use it – go through a practice run in the surgery. Some doctors can loan you a machine for a couple of days. This is the best option because the most reliable electronic machines are the most expensive – a medical centre can buy one or two and keep an eye on their accuracy by regular checks, making sure the cuff is the right size and the batteries fresh. Digital monitors have a cuff, which inflates and deflates at the touch of a button. The Omron has been approved and validated but, for up-to-date advice, contact the British Hypertension Society (see Appendix2).

How is blood pressure measured in the clinic?

Your doctor or nurse takes the blood pressure with an instrument called a sphygmomanometer (often abbreviated to sphyg). It is pronounced ‘s-fig-mo-man-omeater’. The Greek word for pulse is sphygmosand it is the appearance and disappearance of the pulse at the elbow that the doctor or nurse listens for(see Figure 2.5).
While your arm is relaxed and resting on a desk or supported by the doctor or nurse, a rubber cuff is wound round your upper arm just above the elbow. If your arm is large, a big cuff will be used. The cuff is attached to a column of mercury. The cuff is inflated by air being pumped into the cuff; you will feel a squeezing. The pressure in the cuff is increased until the blood flow to your hand is cut off (you may feel a tingling or numbness). Whilst the doctor listens with a stethoscope to the artery at the elbow (the brachial artery, pronounced ‘brake-e-al’), the pressure in the cuff is lowered. The level of mercury shown in the column when the blood begins to flow again (felt as a thumping) is measured as the systolic pressure and, when no noises are heard (you don’t feel this), it is measured as the diastolic pressure. Always ask what your reading is and keep your own records.
The mercury sphyg is being replaced by electronic measuring devices. Your practice may have changed to automatic machines but the cuff will still be put on your arm above the elbow;the wrist devices are not accurate.

How often should my blood pressure be checked?

Once a year if it is normal – try and make a note in your diary to make an appointment for the following year. If it is raised, your doctor will take several readings and keep an eye on it until it is normal. Your blood pressure will then be checked at regular intervals, usually every 3–6 months. Make sure that you ask for this measurement at least twice a year.

My doctor tells me that my systolic pressure is very high, although the diastolic pressure is normal. Does this matter?

It used to be thought that only the diastolic blood pressure rise was important, but modern research has shown that in people over the age of 45 years, the rise in systolic blood pressure over the normal of 140, and certainly over 160, is an important cause of subsequent heart disease and strokes. Treatment of this rise in systolic blood pressure is an important factor in reducing the risk of these serious complications.

My mother had high blood pressure and she suffered a stroke when she was 65. Can I avoid having hypertension myself?

First of all, if someone in your family has had high blood pressure, make sure that you and your relatives have regular check-ups. Although you may feel no benefit now, you may help to prevent illness in the future, so adopt a positive approach:for yourself and those you care about. Other ways of helping yourself include:
•    a healthy diet (see Chapter 9);
•    exercise (see Chapter 10);
•    avoiding getting overweight;
•    avoiding excess alcohol;
•    avoiding eating excess salt.

I’m 62 and my doctor is making me cut down on salt as she says that I am getting more sensitive to salt. What does this mean?

People over 60 years, African-Caribbeans and American Blacks have been found to have less tolerance to too much salt.
Salt-sensitive people can lower their systolic and diastolic blood pressure by 5–10 mmHg by cutting down on salt. Most, however, get a benefit of up to 4 mmHg, but every little bit helps to lower blood pressure and reduce the need for medication.

My husband has been told that he has a high blood pressure. The doctor gave him a diet sheet. How can a better diet help him?

Your husband should not overeat as, apart from anything else, this will make him put on weight, and being overweight is a major risk factor for and cause of high blood pressure. The single most important thing anybody with high blood pressure can do to help themselves is to lose weight. In some lucky people the raised pressure disappears completely and, in others, fewer tablets may be needed. If your husband is overweight, a reducing diet to get him to an optimum weight is an essential part of treatment. Losing 1 kg in weight could take 2mmHg off his systolic blood pressure reading, so losing 3kg (half a stone) can make a borderline pressure normal. However, his pressure will still need watching and will go back up again if the weight is put back on. See Chapter 9 for advice on a healthy diet and how to lose weight.

Treatment
I am bitterly disappointed because I have lost weight and reduced my salt intake, but I have been told that my blood pressure is still raised. What should I do?

You will need medication. Lowering your blood pressure to normal removes your chances of having a stroke and protects your heart, brain and kidneys from damage.
The good news is that treatment is very effective. Controlling high blood pressure helps prevent all the problems developing and restores you to a normal life expectancy.

There seem to be a lot of different medications on the market for raised blood pressure. Why have I been given one and not another?

There are various types of medications in common use. Table 2.2 lists the most commonly prescribed medications for raised blood pressure and Table 2.3 lists some of their possible side effects. The drugs have a generic or chemical name and a trade name under which they may be marketed. The trade names vary between countries so always check against the generic name to make sure that you are on the recommended medication.
Diureticsor ‘water tablets’ are commonly used. They remove excess salt and water from the body. They can also wash out too much potassium (and this may cause cramps) which can be dangerous if digoxin is also being taken. In some people, diuretics cause gout, and if you have diabetes they can raise your blood sugar, upsetting control of your diabetes. Common medications in this group include bendroflumethiazide, indapamide (Natrilix) and chlortalidone (Hygroton) To reduce the loss of potassium, so-called potassium-sparing agents can be prescribed and these include spironolactone, triamterene or amiloride. These two sorts of medications may be combined, as in Aldactide, Moduretic or Dyazide, in order to try and get the best results. Diuretics in general are safe and effective and side effects are not common. Fresh fruit is a good way of replacing potassium – a banana a day may do the trick.
Beta-blockersare now less frequently prescribed. These act to slow your heart rate and lower your blood pressure by blocking the effects of adrenaline. Commonly used medications are atenolol (Tenormin), metoprolol (Betaloc, Lopresor) and bisoprolol (Cardicor). The com ¬monest side effects are cold hands and feet, heavy legs, lethargy and a ‘zombie-like’ feeling. Beta-blockers may cause wheezing and are not used in people with asthma. They may also hide the signs of a low sugar level in people with Type 1 (insulin-dependent) diabetes. They do not tend to mask the perspiration that goes with a hypoglycaemic attack (low sugar episode), so this warning sign is preserved. If the diabetes is stable and well controlled, they are used, but more often if there is also angina present (see Chapter 3).
As a group, the beta-blockers are useful medications, and although they are no longer first line, if you have had a heart attack you may live longer if you are prescribed them. They can be combined with diuretics for an additive effect and may be available with a diuretic in a single tablet, such as Tenoretic.
Calcium antagonistsact to expand the arteries, making it easier for blood to flow (like widening the hose pipe). They can be used with diuretics and some can be used with beta-blockers. The exception is verapamil (Securon, Cordilox, Univer) as the heart rate can get dangerously slow. Calcium antagonists are helpful if you have asthma, and do not affect the medications that you may be receiving if you have diabetes. Commonly prescribed medications are amlodipine (Istin), diltiazem (Tildiem, Adizem, Dilzem), nifedipine (Adalat), verapamil (Securon) and felodipine (Plendil). Side effects include water retention (causing swollen ankles and legs), headaches, constipation (especially verapamil), occasional palpitations and sore gums. Impotence is unusual. Again these are useful medications which seem to be of more value in the elderly and African-Caribbeans. Older people and African-Caribbeans have a different hormone pattern from the kidneys, which makes calcium antagonists more effective.
ACE inhibitors and angiotensin II (AII) antagonists are widely used. ACE stands for angiotensin-converting enzyme. This enzyme is normally present in the body; blocking it causes the blood vessels to relax (the blood pressure falls as it meets less resistance) and reduces salt and water retention. Angiotensin II antagonists act in the same way but at a different point from ACE inhibitors – the end result is the same but the cough side effect of the ACE inhibitors (see below) is usually avoided.
ACE inhibitors include captopril (Capoten, Acepril), lisinopril (Carace, Zestril) and enalapril (Innovace), whilst the AIIs include losartan (Cozaar) and valsartan (Diovan). They both act much the same way by blocking chemicals that constrict the arteries and retain salt and water. If you have heart failure, ACE inhibitors and AIIs can lengthen your life and can protect people with diabetes from kidney damage. The main side effect is a dry hacking cough. These are important medications which have few side effects and are not known to interfere with your quality of life. AIIs do not usually cause problems with men’s erections. ACE inhibitors have recently been shown to benefit patients with coronary artery disease in the absence of high blood pressure or heart failure.
Alpha-blockersact on nerve receptors to dilate the arteries – this in turn lowers the blood pressure. Prazosin (Hypovase) and doxazosin (Cardura) are the most common ones. They can cause tiredness and dizzy feelings. Their major advantage is the reduction in prostate symptoms in a man. They can be combined with all the other medications and are safe in people with asthma or diabetes.
Renin inhibitorsarea new class of drugs that inhibit renin, a kidney hormone. Aliskiren (Rasilez) is now available and acts like ACE inhibitors and AIIs, relaxing the arteries. Diarrhoea can occur and checks on kidney function and blood tests for potassium are advised. Its role at present is limited.

I read in the newspaper and saw a report on TV that calcium antagonists can be dangerous – is this true?

Unfortunately for reasons that are not clear, there were scare stories about calcium antagonists. The evidence has been refuted by other researchers who looked at the claims in depth. Very high doses of nifedipine capsules can cause angina because of the speed of action of this preparation, but the capsules are not used routinely and very rarely in high doses. Claims made of an increased risk of heart attack or cancer do not stand up to careful scientific scrutiny –the claims are so devoid of scientific fact that the stories should not have been put out publicly. Much of what has been written about the dangers of calcium antagonists is nonsense and this has upset many patients and doctors. There is no danger if you take long-acting calcium antagonists, e.g. amlodipine, nifedipine LA (long-acting), and diltiazem LA, but you should avoid short-acting formulations, e.g.nifedipine capsules. The calcium antagonist scares are a classical example of media hype with commercial undertones.

Someone told me that one particular medication for blood pressure makes your hair grow – is this true?

Yes. Minoxidil is a very potent treatment used only in severe resistant blood pressure cases. It can make people put on weight because of water retention and is not used routinely for this reason. It also makes your hair grow – this can be an advantage in bald men but is not usually liked by women!

You have not mentioned Aldomet. I am pregnant and my doctor prescribed this medication for my blood pressure. Why did she choose this rather than the others that you have talked about?

Methyldopa (Aldomet) is an old and effective drug for lowering blood pressure but it does have a large number of side effects. It can cause drowsiness, sluggishness, a dry mouth, depression and impotence (see Chapter 8). Because of these effects, it is not used so much these days and has been replaced by more user-friendly medications. However, it is effective and its main use today is for raised blood pressure in pregnancy, as the medication does not cause harm to your baby. It is usually stopped on delivery to reduce the chances of depression following the birth.

I’ve read about a new medication called Physiotens which was called a breakthrough for blood pressure treatment in my newspaper. Should I get my doctor to put me on it?

Physiotens is the trade name for moxonidine. It acts via the brain and is advised for mild to moderate hypertension if other drugs are not appropriate or are not fully effective. Side effects include dry mouth, headache, fatigue,dizziness and sleep disturbance. It has an effective but limited place in treatment.

When I went to see my doctor, he measured my blood pressure and put me on tablets straight away. Why was this?

If your blood pressure was very high when it was first measured, it would be unlikely that changing your lifestyle alone would help. However, it is worth trying the measures discussed in the section Self-help earlier because these may help to reduce the amount of tablets you need.

I have been feeling tired and lethargic lately. Do you think my tablets are causing the problem?

All medications can cause side effects. We try hard as doctors to prescribe the safest and most convenient medications. If you are concerned that a particular medication is causing a problem, let your doctor know. It may have occurred by chance but it may also be associated with your treatment and a change in your medicine could relieve the symptoms. For instance, if you feel that your sex life has been affected, it may be due to your medications.

I am on treatment for high blood pressure. I know that some medications cause side effects. What should I look for?

If you feel unwell and are taking tablets, do not stop or modify your treatment in any way, but contact your doctor. He will advise what changes or modifications are necessary. This is an important point to remember because a sudden stoppage of treatment can produce what is called a ‘rebound effect’ in the level of blood pressure (it shoots up).
Seek your doctor’s advice if you experience any of the following symptoms, but do not alter your treatment on your own.
•    headaches
•    visual disturbances (blurred vision)
•    shortness of breath
•    chest pain
•    altered ability to concentrate
•    memory loss
•    passing more urine at night
•    sexual problems/erectile dysfunction (impotence)

Remember that some of these symptoms are just as likely to be due to your blood pressure rising as to it being overtreated, so you may need to change, reduce or increase your tablets.

I have heard that blood pressure pills can affect your sex life – is this true?

The short answer is sometimes. The usual complaint is of men failing to get an erection firm enough or lasting long enough for sexual intercourse. Blood pressure itself can cause this problem and only occasionally are the drugs used to treat it, e.g. diuretics, incriminated. If it is drug-induced it will occur in the first 2–4 weeks of therapy and a different drug can then be tried. The least likely drugs to cause male erectile dysfunction (ED) are the AII antagonists (see Table 2.2) and the alpha-blockers. Female problems with lack of arousal have been reported with beta-blockers. Both men and women can get sexual problems as a result of heart disease and sometimes its treatment; if you have a problem, talk about it with your doctor or practice nurse. There is more on this subject in Chapter 8.
While I am taking my tablets, can I lead a normal life or is there anything I should avoid doing?
lthough treatment controls blood pressure effectively through ¬out the day, it is only sensible to avoid as much as possible any events or circumstances that increase your blood pressure, such as highly emotional or stressful situations (see the section Stressbelow)
Keep your weight under control (Chapter 9), moderate your alcohol, fat and salt intake and give up cigarettes if you smoke; you should then be able to live as normal a life as possible, including a normal sex life. Above all, you should not consider yourself an invalid
– you are not!

I am told that I have high blood pressure and need treatment, but I don’t seem to have any symptoms. If I do not feel unwell, why should I need it?

Very often high blood pressure does not make you feel ill. This is possibly because the increase has been gradual over such a long time that you have adjusted to it. However, all the evidence shows that, if high blood pressure is left untreated, you have a greater chance of stroke, heart attacks and complications in the kidneys and eyes. When blood pressure is treated, there is overwhelming evidence that these risks are substantially reduced. Therefore, it is important, and in your interest, to take your medication exactly as prescribed by your doctor, even though you may feel quite well.

Now that I have been prescribed tablets, how long will my treatment last?

The treatment for high blood pressure, whether by lifestyle changes or drugs or both, continues for life, but as many of the medications used in its treatment need to be taken only once daily, interference with your normal lifestyle can be kept to a minimum in the majority of cases. Sometimes, if you have reached your target weight, you may have your tablets reduced or stopped, in order to see if you still need them. Ask your doctor if this is worth a try for you.

I don’t mind taking one tablet a day, but one of my friends has so many that she rattles. Will these tablets be all that I need to take?
Most blood pressure patients end up on more than one medication. With some patients other factors or conditions may complicate the situation and treatment for these may also be required; you may then have to take several tablets a day. For example, if you develop angina, the tablets may need to be changed to relieve you of your chest pain (see the section Treatment in Chapter 3). If you develop diabetes, specific diabetic tablets may be needed. We try to tailor the treatment to the individual, aiming to keep your quality of life as good as possible – so if a diuretic causes gout, we can change to a beta-blocker, and so on. We try to give you the minimum of inconvenience, but also to keep you in good health.

My blood pressure seems to be resistant to many drugs and I have now been put on spironalactone. How is this different?

Spironalactone is a diuretic (water tablet) that antagonises a hormone called aldosterone. It can be very useful when the blood pressure is proving difficult to control. Kidney function needs to be monitored, and as it retains potassium caution is needed if used with ACE inhibitors or AIIs. The commonest side effects are stomach upsets and swollen breasts, mainly in men (gynaecomastia), which can be painful. Erection problems in men, and period changes in women, can also occur.

What should I do if I forget to take my tablets?

For most people, there is no need to worry, as the blood pressure will only rise slowly, so you can get back on schedule the next day. If you are on a beta-blocker and also have angina, you should take the medication immediately you realise that you have forgotten it, as a means of catching up.